Declining Rates of Orthopedic Surgery Among Patients With Multiple Myeloma- Associated Skeletal Lesions

Abstract Background Multiple myeloma (MM) frequently causes osteolytic skeletal lesions and pathologic fractures. Advances in systemic therapy and bone-modifying agents may have reduced the need for orthopedic surgical intervention. The aim of this study was to evaluate temporal trends in orthopedic surgical intervention among patients with MM. We hypothesized that orthopedic surgery rates have declined over time. Methods This retrospective observational cohort study used data from the national Veterans Affairs (VA) Cancer Registry and the Centers for Medicare & Medicaid Services databases between 2008 and 2024. Patients aged 50 years or older with newly diagnosed MM from 2008 to 2024 were included. The primary outcome was the rate of any orthopedic surgery within 3 years of diagnosis, assessed in consecutive 3-year intervals; patients were followed from diagnosis until surgery, death, or end of available follow-up, and were censored accordingly. Kaplan-Meier analysis and multivariable Cox proportional hazards models were used to evaluate time to first surgery, adjusting for age, sex, race, frailty (VA Frailty Index), and comorbidity (Charlson Comorbidity Index). Results There were 10,171 patients (median age 69.3 years; 96.8% male). The rate of any orthopedic surgery within 3 years of MM diagnosis declined from 10.6% (2008–2010) to 4.3% (2020–2022). Declines were observed across all procedure categories: spine surgery (5.1% to 2.3%), extremity fixation (6.0% to 2.3%), and arthroplasty (2.2% to 0.5%). In adjusted models, patients diagnosed in 2018–2024 had a significantly lower hazard of surgery than those diagnosed in 2008–2012 (HR 0.42; 95% CI 0.35–0.50). Severe frailty was associated with a higher likelihood of surgery (HR 1.91; 95% CI 1.31–2.76), whereas greater comorbidity was associated with a lower likelihood of surgery. Conclusions Rates of orthopedic surgery among patients with MM declined significantly despite increasing frailty and comorbidity, coinciding with the adoption of modern systemic therapy and bone-modifying agents. Surgery remains essential for select patients with mechanical instability or neurologic compromise. Understanding these shifts in surgical utilization can inform multidisciplinary treatment planning, optimize patient selection, and reduce morbidity in the modern era of MM care.